Student Perceptions of the Pharmacist's Approach across the Varying Levels of Medication Therapy Management Services

By Hohmeier, Kenneth C.; Spivey, Christina et al. | American Journal of Pharmaceutical Education, February 2018 | Go to article overview

Student Perceptions of the Pharmacist's Approach across the Varying Levels of Medication Therapy Management Services


Hohmeier, Kenneth C., Spivey, Christina, Collier, Cristyn, Chisholm, Marie-Burns, American Journal of Pharmaceutical Education


INTRODUCTION

Medication therapy management (MTM) is a service most commonly performed by pharmacists to identify and resolve medication-related problems, and has been shown to both reduce health care costs and improve clinical outcomes. (1) The largest national reimbursable, economically viable and scalable MTM program in the US has been administered by the Centers for Medicare and Medicaid Services (CMS) under the prescription drug benefit (Part D). Both privately administered prescription drug plans (PDPs) and Medicare Advantage plans (MA-PDs) are required by CMS to offer two levels of MTM referred to as comprehensive medication reviews (CMRs) and targeted medication reviews (TMRs) to certain beneficiaries at high risk for medication-related problems. (2) ACMR is an annual interactive, person-to-person, or telehealth consultation performed by a pharmacist or other qualified provider, and a TMR is a single-medication specific consultation used primarily to address non-adherence or therapy omission (2). To meet these requirements, several MA-PDs and PDPs contract with community pharmacists either directly or indirectly to deliver these services at the beneficiary's local pharmacy.

Surprisingly, despite the profession's realization of this highly sought after opportunity to provide reimbursable, direct patient care services in a community pharmacy setting, the provision of MTM, and in particular CMRs, has been slow and sporadic. These low provision rates are a priority concern for CMS, as evidenced by a recent decision to track and evaluate Part D MTM completion rates as part of their medication-related quality measures program. (3) As of 2014, MTM completion rates for CMRs were only 15.4% for PDPs and 30.9% for MA-PDs. (4)

Both time- and workflow-related barriers are commonly cited as impediments to MTM provision, yet in practice, community pharmacies within the same organization and with the same general work environments will have drastically different rates of CMR completion. (5,6) Without concrete answers as to why MTM implementation has not been rapidly adopted, the general question may be asked, "are pharmacists capable of consistently providing direct patient care in their practices, especially in the community pharmacy setting?"

The answer underlying these low MTM implementation rates in the community pharmacy is complex and multi-factorial. The financial sustainability of the MTM program is an important factor. Unlike inpatient clinical pharmacy services, outpatient clinical pharmacy services must be tied to revenue generation and must ultimately break-even or return a profit. Given that there are commonly only two types of reimbursable MTM services in the community pharmacy (CMR and TMR), these pharmacists are confined to the levels of care specified by CMS--which is in general, less comprehensive than the care offered by a pharmacist providing services in an ambulatory care environment. (7) The community pharmacist's role in the patient care team and access to patient medical information are likely also a contributor. Within the outpatient care arena, the ambulatory care pharmacist has access to a patient's medical information and plays a predefined role in the team with an established relationship with one or more of the patient's providers. In contrast, the community pharmacist typically does not have access to medical data or a formalized role in the patient care team.

These factors--undefined role in the health care team, incomplete access to patient information, and narrowly defined levels of care that can be provided--may shed light into the more hidden, or latent barriers to MTM implementation. And each of these factors directly adds to the amount of time and effort required to provide direct patient care in the community. For example, the faxing of a prescriber for pertinent medical information necessary to appropriately workup a patient, followed by the subsequent fax to make recommendations, may be many times more time consuming than seeking information and making recommendations in an ambulatory care environment. …

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